i , ;  ■ 


f<t  ■'  * 


NSTITUTE,    BULLETIN    No.    17 

HX0001 5261  ?  Public  Health  and  Marine-Hospital  Service 

WALTER  WYMAN,  Surgeon-General 


THE  PROPHYLAXIS  OF 
YELLOW  FEYEP 


BY 


G.  M.  GUITEKAS 


FEBRUARY,     1 909 


WASHINGTON 

GOVERNMENT  PRINTING  OFFICE 

1909 


YELLOW    FEVER     INSTITUTE,    BULLETIN    No.    17 

Treasury  Department,  U.  S.  Public  Health  and  Marine-Hospital  Service 
WALTER  WYMAN,  Surgeon- General 


THE  PROPHYLAXIS  OF 
YELLOW  FEVER 


BY 


G.  M.  GUITERAS 


FEBRUARY,     1909 


WASHINGTON 

GOVERNMENT  PRINTING  OFFICE 

1909 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/prophylaxisofyelOOguit 


YELLOW    FEVER    INSTITUTE 

Treasury  Department,  Bureau  of  Public  Health  and  Marine-Hospital  Service. 
WALTER   WTMAN,  Surgeon-General. 

Bulletin  No.  17. 

THE  PROPHYLAXIS  OF  YELLOW  FEVER. 


By  G.  M.  Gttiteras,  Surgeon,  U.  S.  Public  Health  and  Marine-Hospital  Service. 


The  study  of  yellow  fever  has  ever  been  an  interesting  one  from 
the  time  it  was  first  observed  in  the  Western  Hemisphere  to  the 
present  day. 

Whether  the  disease  is  indigenous  to  America  or  was  introduced 
from  the  west  coast  of  Africa,  is  a  mooted  question.  From  the  his- 
torical data  which  we  have  on  the  subject  it  would  appear  as  though 
the  latter  opinion  was  the  correct  one. 

The  disease  has  been  a  scourge  to  the  fair  and  fertile  regions  of 
tropical  and  subtropical  America  and  has  greatly  retarded  their 
material  progress.  Its  existence  in  an  endemic  form  at  various 
points,  such  as  Habana,  Rio  de  Janeiro,  and  Vera  Cruz,  has  given 
these  ports  an  unenviable  reputation  with  travelers  and  seriously 
hampered  their  commercial  interests,  and  carried  from  these  foci 
to  other  infectible  territory  it  has  caused  widespread  epidemics 
resulting  in  great  loss  of  life,  interference  with  commerce,  and  finan- 
cial disaster. 

The  peculiar  characteristics  of  the  disease  and  the  mystery  which 
shrouded  its  etiology  and  method  of  propagation  have  invested  it 
with  remarkable  interest,  and  in  our  day  the  solution  of  this  mys- 
tery, in  so  far  as  the  method  of  propagation  is  concerned,  has  given 
us  one  of  the  most  important  advances  in  modern  science. 

The  work  of  the  United  States  Army  Board  in  establishing  beyond 
a  doubt  the  hypothesis  enunciated  by  Carlos  Finlay,  in  1881,  as  to 
the  transmission  of  yellow  fever  by  the  mosquito,  was  indeed  bril- 
liant. I  had  the  pleasure  of  being  present  at  the  International  Sani- 
tary  Congress  held   in   Habana    when   Doctor   Heed   presented   his 

(3) 


memorable  report  proclaiming  the  new  dogma.  The  work  therein 
described  was  so  thorough  and  the  results  so  clearly  established  as  to 
leave  no  doubt  in  the  minds  of  his  hearers  as  to  the  truth  of  his  con- 
clusions. Considering  the  number  of  able  men  who  had  been  study- 
ing the  subject,  it  is  remarkable  that  a  period  of  nearly  twenty  years 
should  have  elapsed  before  Finlay's  ideas  were  seriously  considered 
and  finally  accepted.  It  is  still  more  remarkable  when  we  consider 
that  since  the  early  part  of  the  nineteenth  century  various  observers 
had  indicated  the  mosquito  as  in  some  way  related  to  the  disease 
under  consideration.  There  is  no  doubt  but  that  the  interesting  work 
of  Dr.  Henry  R.  Carter,  of  the  Public  Health  and  Marine- Hospital 
Service,  in  establishing,  in  1898,  the  "  extrinsic  "  period  of  incubation 
of  yellow  fever — that  is,  the  interval  between  the  infecting  and  sec- 
ondary cases — gave  renewed  impetus  to  the  study  of  the  mosquito  as 
a  factor  in  yellow  fever  and  indirectly  brought  about  the  confirma- 
tion of  the  truth  of  the  hypothesis  of  Doctor  Finlay. 

PRINCIPLES  OF  PROPHYLAXIS. 

The  prophylaxis  of  3Tellow  fever,  which  up  to  a  few  years  ago  was 
founded  on  ideas  so  uncertain  and  insecure,  is  to-day  firmly  based 
on  the  discovery  of  the  transmitting  agent  of  the  disease.  This  agent 
can  be  destroyed  and  may  be  prevented  from  becoming  itself  inocu- 
lated and,  if  inoculated,  from  transmitting  the  disease  to  the  well. 

In  the  abstract  the  measures  necessary  to  accomplish  this  are  per- 
fectly feasible.  Xo  extraordinar}^  means  or  intelligence  is  required 
to  make  them  effective;  only  a  careful  attention  to  details.  But  in 
practice,  when  the  peculiarities  of  human  nature,  the  rights  of  the 
individual  as  guaranteed  by  the  law,  and  the  ignorance  of  the  people 
have  to  be  taken  into  account,  the  problem  becomes  both  difficult  and 
onerous. 

The  subject  of  the  prophylaxis  of  yellow  fever  has  been  thoroughly 
thrashed  out  during  the  last  few  years,  and  as  the  matter  is  so  simple 
in  itself  there  is  but  little  that  may  be  added  to  what  has  already 
been  said.  Within  the  time  stated  the  writer  has  been  connected 
with  the  two  epidemics  which  have  occurred  in  the  United  States — at 
Laredo,  Tex.,  in  1003,  and  at  New  Orleans  and  Vicksburg  in  the  gen- 
eral epidemic  of  1005 — and  has  carried  out  with  success  the  principles 
of  prophylaxis  which  will  be  referred  to  in  this  article.  It  is  not. 
however,  the  purpose  to  enter  herein  into  the  minutiae  of  the  meth- 
ods of  prophylaxis,  but  rather  to  invite  attention  to  some  of  the 
difficulties  to  be  encountered  and  to  suggest  some  of  the  means 
whereby,  in  the  opinion  of  the  writer,  the  obstacles  found  in  the 
practical  application  of  the  principles  involved  may  be  lessened  or 
eliminated. 


IMPORTANCE  OF  EARLY  DIAGNOSIS. 

The  knowledge  that  we  now  have  of  the  transmission  of  yellow 
fever  gives  us  a  secure  basis  upon  which  to  lay  our  plans  against  the 
introduction  of  the  disease  or  to  prevent  its  spread  when  introduced. 
There  is,  however,  one  link  wanting  to  give  us  absolute  control  of  the 
disease,  and  that  is  the  etiological  factor.  The  consensus  of  opinion 
up  to  the  present  time  is  that  it  is  a  micro-organism,  ultramicroscopic, 
and  as  yet  beyond  our  means  of  detection.  The  importance  of  deter- 
mining this  causative  agent  is  apparent  from  every  point  of  view,  but 
especially  so  as  an  aid  to  diagnosis,  for  the  prompt  and  positive  diag- 
nosis of  yellow  fever  is  one  of  the  most  important  factors  in  the  pro- 
phylaxis of  the  disease,  especially  when  it  appears  in  a  locality  where 
it  was  previously  unknown  or  that  has  been  free  of  it  for  some  time. 

In  order  to  take  measures  against  the  spread  of  a  disease  it  is  first 
of  all  necessary  that  we  should  be  aware  of  its  presence.  In  the  case 
of  yellow  fever  considerable  embarrassment  presents  itself  in  deter- 
mining this  fact,  both  on  account  of  the  inherent  difficulty  in  making 
the  diagnosis  and  the  natural  fear  of  the  attending  physician  of  the 
alarm  and  other  unfortunate  consequences  which  will  usually  follow 
a  declaration  of  its  presence,  and  especially  the  fear  that  he  may  be, 
after  all,  mistaken  in  the  diagnosis.  This  applies  particularly  to 
those  localities  where  yellow  fever  is  a  new  or  an  infrequent  visitor 
and  where  there  exists  an  unreasonable  fear  of  the  disease. 

It  is  foreign  to  the  purpose  of  this  paper  to  enter  into  a  discussion 
of  the  differential  diagnosis  of  yellow  fever,  but  I  desire  to  impress 
upon  the  reader,  the  importance,  from  a  prophylactic  point  of  view, 
of  the  early  diagnosis  of  all  cases  of  this  disease.  We  know  that  the 
Stegomyia  calopus  can  only  become  infected  by  biting  the  patient 
during  the  first  three  days  of  the  illness ;  hence  the  diagnosis  should 
be  made  in  its  very  incipiency.  Frequently  it  is  not  easy  to  do  this, 
especially  in  mild  cases.  It  is  here  that  our  knowledge  is  at  fault  and 
all  our  energies  should  be  bent  to  discover  some  means  of  making  a 
positive  diagnosis,  one  which  can  not  be  controverted.  When  this  is 
achieved  the  citadel  will  have  been  won  and  the  last  vestige  of 
danger  from  this  disease  removed. 

USUAL  CONDITIONS  WHEN  YELLOW"  FEVER  IS  DEOLAEED. 

Under  present  circumstances  the  following  conditions  almost  inva- 
riably confront  us  in  an  outbreak  of  yellow  fever  in  a  locality  usually 
free  from  it,  such  as,  for  instance,  our  South  Atlantic  and  Gulf 
coast:  A  case  of  fever  presents  itself  to  a  physician  who  is  not  on 
the  lookout  for  yellow  fever  and  who  perhaps  has  never  seen  the 
disease.  If  it  be  a  mild  case  of  }^ellow  fever,  it  will  probably  get 
well  without  his  suspicions  being  even  aroused.     If,  however,  it  be 


of  moderate  severity  and  the  physician  careful  and  observant,  he  will 
soon  note  symptoms  which  do  not  square  with  the  fevers  which  he  has 
been  accustomed  to  see.  He  may  then  suspect  that  all  is  not  right 
and  begin  to  think  of  the  possibility  of  yellow  fever.  Immediately 
the  purely  medical  and  scientific  character  of  the  case  becomes 
clouded  by  the  material  considerations  involved.  Is  the  diagnosis 
positive?  Shall  the  case  be  reported  or  not?  From  where  could 
the  infection  have  come?  This  last  question  is  always  given  undue 
weight,  with  fatal  results,  because  as  a  rule  it  is  impossible  to  answer, 
and  its  consideration  leads  to  uncertainty  and  delay.  But  why 
should  we  pause  to  answer?  Do  we  do  so  in  a  case  of  measles,  scar- 
latina, or  smallpox?  Why  not  make  the  diagnosis  on  the  symptoms 
of  the  disease  as  presented  to  us  and  not  bother  at  that  critical  mo- 
ment with  the  abstruse  study  of  its  possible  origin?  That  surely 
would  be  the  most  rational  and  practical  way  to  proceed.  In  any 
case,  it  is  indeed  a  heavy  responsibility  to  satisfactorily  answer  these 
questions  under  the  conditions  at  present  affecting  our  Southern 
States  or  other  localities  similarly  placed.  The  usual  course  of  action 
is  as  follows:  The  attending  physician  will  consult  with  his  con- 
freres. Some  will  opine  that  it  is,  others  that  it  is  not,  yellow  fever. 
One  who  has  had  some  experience  with  the  disease,  a  so-called 
expert,  is  finally  called  in  and,  we  will  presume,  verifies  the  diagnosis 
of  yellow  fever.  As  an  immediate  result  of  this  declaration  the 
physicians  of  the  place,  and  with  them  the  public,  divide  into  two 
antagonistic  camps,  one  maintaining  that  the  disease  is  3rellow  fever, 
the  other  that  it  is  not.  And  thus,  with  much  wrangling  and  dis- 
order and  under  the  most  discouraging  circumstances,  the  work 
of  preventing  the  spread  of  the  disease  is  inaugurated.  The  effort 
to  stamp  it  out  then  becomes  a  veritable  campaign,  not  only  against 
the  mosquito,  but  against  a  usually  small  but  determined  party  of 
opposition  among  the  people.  Such  a  condition  of  affairs  would 
not  exist  if  the  diagnosis  could  be  promptly  established  beyond  ques- 
tion or  cavil. 

To  attain  this  being  impossible  with  the  diagnostic  means  at 
present  at  our  command,  I  pass  on  to  speak  of  what  seems  to  me  a 
most  important  indirect  prophylactic  measure,  one  which  may  do 
much  to  offset  the  results  of  our  present  inefficiency  to  promptly 
establish  an  absolutely  correct  diagnosis — and  that  is  education. 

EDUCATION  AS  A  PROPHYLACTIC  FACTOR 

The  people  in  general,  and  the  medical  profession  as  well,  should 
be  taught  the  truth  about  yellow  fever,  its  comparatively  low  mor- 
tality as  treated  at  present,  and  the  facility  with  which  the  disease  may 
be  avoided  and  controlled.    In  a  community  which  is  well  informed 


on  these  points  the  presence  of  a  case  of  yellow  fever  could  be  an- 
nounced without  any  fear  of  alarm  or  panic  and  the  measures  to 
prevent  its  propagation  put  in  force  at  once  without  clamor  or  delay. 
The  physician  could  act  simply  on  the  merits  of  the  case  from  a  pro- 
fessional standpoint.  If  the  disease  under  observation  presented  the 
symptoms  of  yellow  fever,  he  would  announce  it  as  such  without 
stopping  to  consider  or,  for  the  time  being,  trying  to  determine  from 
whence  it  came  or  obscure  his  judgment  with  considerations  as  to  the 
effect  of  his  diagnosis  on  the  business  interests  of  the  locality  or  on 
his  own  personal  interests.  Such  a  condition  of  affairs  is  much  to  be 
desired  and  with  patience  and  preserverance  may  be  attained. 

The  education  of  the  public  on  this  subject  acts  not  only  in  this 
indirect  manner,  but  directly  as  well,  for  it  will  so  guide  public 
opinion  that  it  will  be  possible  to  practically  eliminate  the  transmit- 
ting factor  of  the  disease,  the  mosquito,  the  stegomyia  calopus.  And 
as  it  is  impracticable  to  select  only  the  stegomyia  calopus  for  destruc- 
tion, a  campaign  against  this  mosquito  must  be  a  general  one,  and  also 
include  those  responsible  for  the  transmission  of  malaria,  filaria,  etc., 
thus  removing  from  the  Tropics  and  subtropics  some  of  the  most 
important  causes  of  morbidity  and  mortality,  and  which  heretofore 
have  been  serious  obstacles  to  their  political,  commercial,  and  indus- 
trial progress.  Education  on  this  subject,  therefore,  I  consider  of 
prime  importance  in  the  prophylaxis  of  yellow  fever,  and  it  is  sur- 
prising how  little  has  been  done  or  is  being  done  on  this  line. 

The  writer  in  his  report  to  the  surgeon-general  on  the  yellow  fever 
epidemic  at  Laredo,  Tex.,  in  1903,  said : 

"  Insistent  and  continued  efforts  should  be  made  through  the  public 
press  and  other  available  means  to  educate  the  people  within  the 
sphere  of  influence  of  the  stegomyia  fasciata  (calopus),  so  that  they 
will  learn  to  protect  themselves  against  the  invasion  or  spread  of 
yellow  fever  among  them  by  destroying  the  means  for  the  propaga- 
tion of  said  mosquito  and  by  protecting  themselves  against  the  mos- 
quito by  efficient  screening.  Above  all,  to  eradicate  the  existing  fear 
in  the  medical  profession  as  well  as  among  the  laity,  of  declaring 
the  presence  of  yellow  fever.  If  the  first  case  presenting  the  slightest 
suspicious  symptoms  of  that  disease  were  promptly  made  public  and 
the  proper  modern  precautions  taken,  there  would  be  no  danger  of 
the  disease  spreading.  In  fact,  the  public  should  be  taught  to  ac- 
knowledge the  existence  of  yellow  fever  in  their  midst  with  the  same 
equanimity  as  they  do  in  the  case  of  measles  or  scarlatina." 

And  again,  in  the  report  of  the  epidemic  in  Vicksburg,  Miss'.,  in 
1905,  the  writer  stated : 

"  There  is  still  much  ignorance  and  skepticism  (on  the  subject  of 
the  method  of  transmission  of  yellow  fever).     An  effort  should  be 


8 

made  to  overcome  this  by  widely  distributing  pertinent  literature  on 
the.  subject.  And  as  it  is  reasonable  to  suppose  that  in  spite  of  the 
progress  already  made  and  being  made  to  eradicate  this  disease  from 
Tropical  and  subtropical  America,  it  will  continue  to  harass  us  for 
many  years  to  come,  it  is  believed  that  a  campaign  of  education 
should  be  begun  with  the  young.  All  important  facts  pertaining  to 
the  transmission  of  yellow  fever  by  the  stegomyia  fasciata  (calopus), 
and  the  mode  of  propagation  of  this  mosquito  should  be  taught  in 
the  public  and  private  schools  and  colleges  in  infectible  territory. 
There  may  be  seen  in  this  way  a  good  chance  to  completely  destroy 
the  stegomyia  in  its  present  habitat,  and  even  if  not  successful  in 
entirely  destroying  it,  the  great  advantage  will  have  been  gained  that 
when  yellow  fever  should  make  its  appearance  in  a  locality  the  work 
of  the  sanitarian  in  checking  or  stamping  out  the  disease  would  be 
made  easy  indeed  and  the  usual  panic  with  its  discomforts  and 
financial  losses  avoided." 

My  experience  in  these  two  epidemics  and  what  I  have  seen  else- 
where has  confirmed  in  my  mind  the  importance  of  this  matter.  I  be- 
lieve and  would  recommend  that  the  method  of  transmission  of  yellow 
fever,  and  malaria  as  well,  be  taught  in  the  schools  wherever  these 
diseases  are  liable  to  occur.  The  subject  should  be  taught  in  the  pri- 
mary grades,  for  what  children  then  learn  they  will  retain.  To 
obtain  the  desired  result  the  most  elementary  teaching  would  suffice. 
Children  may  be  taught  to  dread  a  mosquito  as  they  now  do  other 
insects  that  are  less  harmful.  In  the  higher  grades,  with  little  labor 
cr  time,  the  reasons  for  this  fear  of  the  mosquito  may  be  demon- 
strated, as  also  the  methods  of  exterminating  the  insect  and  of  pro- 
tecting one's  self  against  its  bite. 

ULTIMATE  KESULTS  OP  EDUCATION. 

With  the  above  idea  disseminated  among  the  people  it  would  not 
be  long  before  public  opinion  would  demand  with  irresistible  force  the 
drainage  of  swamps  and  lowlands  and  the  inspection  of  houses  and 
premises  to  see  that  they  were  free  of  breeding  places  for  mosquitoes. 

To  have  open  cisterns,  water  barrels,  bottles,  broken  crockery,  or,  in 
fact,  any  receptacle  capable  of  holding  water  exposed  for  any  length 
of  time,  would  be  considered  as  much  a  nuisance  and  a  menace  to 
(lie  public  health  as  ill-ventilated  and  crowded  tenements,  dirty 
sheet-,  defective  sewerage,  and  the  many  other  dangers  which  at 
present  excite  the  social  and  political  activities  of  national,  state,  and 
municipal  authorities.  Such  a  system  would,  within  a  comparatively 
short  time,  eliminate  all  danger  from  both  yellow  fever  and  malaria. 


PROPHYLACTIC  MEASURES  INDICATED  IN  INFECTIBLE  TERRITORY. 

We  will  now  consider  more  in  detail  the  prophylactic  measures  that 
should  be  observed  in  infectible  territory.  These  may  be  divided 
into  two  classes,  to  wit :  (a)  Measures  directed  against  the  introduc- 
tion of  yellow  fever  from  abroad;  (b)  those  looking  to  the  prevention 
of  its  spread  when  it  has  been  introduced. 

Maritime  quarantine. — Measures  employed  to  prevent  the  entrance 
of  infection  from  abroad  are  usually  included  under  the  term  "  mari- 
time quarantine  "  and  are  at  present  well  provided  for  in  the  United 
States  by  an  efficient  national  quarantine  establishment,  which  is  an 
integral  part  of  the  United  States  Public  Health  and  Marine-Hos- 
pital Service. 

The  measures  ordained  against  the  introduction  of  yellow  fever  by 
the  quarantine  regulations  of  this  service  are  based  on  its  well-known 
period  of  incubation  and  the  processes  of  disinfection  on  the  mos- 
quito transmission  of  the  disease,  and  are  directed  to  the  destruction 
of  this  insect  both  in  its  larval  and  adult  stage.  These  measures  may 
be  stated  briefly  as  follows: 

Vessels  which  may  possibly  be  infected  are  detained  at  the  port  of 
arrival  five  days  after  disinfection ;  vessels  known  to  be  infected,  six 
days.  The  service  has  medical  officers  stationed  at  all  the  important 
ports  within  the  yellow-fever  zone,  and  if  the  vessel  is  disinfected  at 
the  port  of  departure  under  the  supervision  of  this  officer,  the  vessel 
on  arrival  at  a  port  of  the  United  States  within  the  infectible  area 
is  subject  to  the  following  modified  treatment:  If  arriving  in  five 
days  or  less,  she  may  be  admitted  to  pratique  without  disinfection  or 
further  detention  than  is  necessary  to  complete  the  five  days.  If  ar- 
riving after  five  days  and  within  ten  days,  she  may  be  immediately 
fumigated  and  admitted  without  detention.  If  arriving  after  a 
longer  voyage  than  ten  days,  she  will  be  considered  as  not  having 
been  subjected  to  any  previous  treatment.  This  last  disposition  is 
based  on  the  possibility  that  a  case  of  yellow  fever  may  have  occurred 
aboard  and  recovered  within  the  time  mentioned. 

Passenger  traffic  from  infected  ports,  without  detention,  is  also 
permitted  by  these  regulations  under  the  following  conditions : 

Vessels  carrying  such  passengers  must  be  in  the  best  sanitary  con- 
dition and  must  lie  at  approved  moorings  in  the  open  harbor.  The 
crew  must  not  be  allowed  ashore  at  the  port  of  departure.  The 
entrance  of  mosquitoes  into  the  vessel  must  be  prevented,  and  if  they 
do  find  ingress  must  be  destroyed.  Passengers  and  crew  must  be 
certified  as  immune  by  the  medical  officer  issuing  the  bill  of  health. 
The  evidences  of  immunity  which  may  be  accepted  are  proof  of  a 
previous  attack  or  ten  years'  residence  in  an  endemic  focus  of  yellow 
fever.  These  regulations  apply,  of  course,  only  during  the  close  quar- 
antine season — that  is,  from  the  1st  of  May  to  the  1st  of  November. 


10 

It  will  be  noted  that  the  above  restrictions  are  liberal  enough  and 
at  the  same  time  give  adequate  protection. 

Referring  for  a  moment  to  the  evidence  upon  which  certificates  of 
immunity  are  based,  the  writer  is  of  the  opinion  that  a  ten  years' 
residence  in  an  endemic  focus  should  no  longer  be  considered  suffi- 
cient, for  with  our  present  knowledge  of  the  method  of  transmission 
of  yellow  fever  it  is  quite  clear  that  any  intelligent  person  taking- 
certain  simple  precautions  might  very  well  live  a  lifetime  in  an 
endemic  focus  and  yet  never  be  exposed  to  infection. 

Measures  against  the  spread  of  yellow  fever. — With  reference  now 
to  class  o — that  is,  preventive  measures  against  the  spread  of  yellow 
fever  once  it  has  been  introduced,  we  find  that  as  a  rule  we  are  not 
so  well  equipped.  The  principle  of  prophylaxis  is,  of  course,  pre- 
cisely the  same,  but  is  much  more  difficult  of  application  because  we 
have  to  deal  with  local  and  conflicting  interests  and  the  ignorance 
of  the  people.  Municipalities  usually  have  a  sufficiency  of  ordi- 
nances and  regulations  covering  prophylactic  measures  against  yellow 
fever,  but  unfortunately  these  are  completely  ignored  except  when 
menaced  by  an  epidemic,  and  then  enforced  with  difficulty.  These 
ordinances  have  been  enacted  during  a  period  of  stress  and  excite- 
ment, when  yellow  fever  was  present  or  dangerously  near,  and  quickly 
forgotten  once  the  danger  had  passed.  Now,  this  should  not  be,  for 
there  is  no  reason  why  every  port  in  infectible  territory  should  not 
be  so  administered  as  to  make  it  noninfectible,  so  that  if  yellow  fever 
should  gain  an  entrance  from  abroad  its  spread  would  be  impossible. 
To  attain  this  I  would  outline  the  following  plan :  Education  and  the 
formation  of  a  public  opinion  that  would  look  upon  the  mosquito  not 
only  as  a  disagreeable  pest  but  a  very  dangerous  one  as  well ;  proper 
drainage;  a  corps  of  inspectors  to  examine  all  premises  every  ten 
days,  preferably  once  a  week,  to  see  that  they  are  free  from  water 
containers  capable  of  harboring  mosquito  larvae;  the  screening  or 
covering  with  oil  of  water  containers  which  can  not  be  destroyed,  or 
the  use  of  small  fish  where  the  above  methods  are  not  available; 
the  removal  of  unnecessary  vegetation:  the  screening  of  dwellings 
and  other  buildings. 

In  carrying  out  the  above  measures  there  is  nothing  that  requires 
any  great  expenditure  of  money  or  labor,  and  if  efficiently  performed 
and  consistently  kept  up  it  would  be  but  a  short  time  before  the  intro- 
duction of  a  case  of  yellow  fever  into  a  locality  so  governed  would  be 
unattended  with  danger  and  scarcely  cause  a  ripple  of  excitement. 

GENERAL  PLAN  FOE  HANDLING  AN  EPIDEMIC. 

Where  the  ideal  conditions  above  mentioned  do  not  prevail  there  is, 
of  course,  imminent  danger  of  the  disease  spreading.  Steps  must  be 
taken  :it  once  to  prevent  this.     The  bases  of  preventive  measures  may 


11 

be  stated  succinctly  as  follows :  To  prevent  the  infection  of  Stegomyia 
mosquitoes  by  properly  protecting  all  persons  ill  with  yellow  fever 
during  the  first  three  days  of  the  illness ;  to  protect  the  well  from  the 
bite  of  the  mosquito ;  and,  as  a  corollary  to  the  above,  the  destruction 
of  all  mosquitoes  and  their  means  of  propagation.  Given  the  requi- 
site personnel,  sufficient  funds,  and  the  necessary  authority  to  enforce 
measures  to  this  effect  and  there  would  be  little  danger  of  the  disease 
spreading.  These  desiderata,  however,  are  usually  wanting  or  only 
imperfectly  supplied.  The  practical  adaptation  of  the  above  propo- 
sitions may  be  considered  under  the  following  heads : 

1.  Detection  of  cases  or  inspection. 

2.  Yellow  fever  hospital. 

3.  Martial  law. 

4.  Detention  camp. 

5.  Protection  against  the  bite  of  the  mosquito;  screening,  etc. 

6.  Extermination  of  mosquitoes,  including  oiling,  fumigation  and 
the  screening  or  destruction  of  water  containers. 

The  details  of  the  two  latter  are  so  well  known  and,  in  fact,  so 
simple  that  it  seems  unnecessary  to  take  up  the  reader's  time  with  a 
discussion  of  them.  Relative  to  the  first  three,  which  I  consider  of 
great  importance  and  which,  in  a  way,  form  the  tripod  on  which  the 
others  rest,  it  is  well  to  say  a  few  words. 

1.  Detection  of  cases  or  inspection. 

In  order  to  put  in  force  efficient  prophylactic  measures  it  is  abso- 
lutely necessary  that  all  cases  be  reported  immediately.  For  reasons 
before  stated  this  is  difficult,  and  to  those  already  given  we  may  add 
that  during  an  epidemic  many  cases  of  fever  do  not  call  a  phy- 
sician at  all.  To  surmount  these  obstacles,  as  well  as  the  difficulty  of 
definitely  recognizing  the  disease  in  its  early  stages,  all  cases  of 
pyrexia  in  which  the  reason  of  the  abnormal  temperature  is  not 
manifest  should  be  treated  prophylactically  during  the  first  three 
days  as  though  they  were  yellow  fever,  or  until  a  positive  diagnosis 
to  the  contrary  is  made.  For  the  purpose  of  reaching  all  cases  of 
fever  a  thorough  inspection  is  required.  Every  dwelling  in  the  in- 
fected area  must  be  inspected  daily,  or,  better,  twice  a  day,  by  com- 
petent inspectors,  persons  capable  of  reading  the  clinical  thermometer. 
All  cases  of  pyrexia  discovered  by  the  inspectors  should  be  imme- 
diately reported  to  the  officers  in  charge  of  the  screening  and  fumi- 
gating parties  for  proper  action.  The  patient  having  been  protected 
against  the  bite  of  the  mosquito  by  screening  and  his  dwelling  and 
the  surrounding  houses  fumigated  for  the  purpose  of  destroying  any 
possibly  infected  mosquitoes,  the  question  of  diagnosis  may  safely 
be  left  to  be  determined  later.  Whenever  possible  the  patient  should 
be  removed  to  the  hospital. 


L2 

2.  Yellow-fever  hospital. 

This  brings  us  to  the  second  prophylactic  measure  advocated 
above — the  advantage,  and  indeed  necessity,  of  a  yellow-fever  hos- 
pital in  dealing  successfully  with  an  epidemic. 

There  is  a  prejudice  among  the  people  against  the  term  "  yellow  - 
fever  hospital,"  hence  it  would  be  as  well  to  yield  to  this  prejudice 
and  call  it  an  "  isolation  "  or  "  observation  "  hospital.  The  important 
point  is  that  this  hospital  be  absolutely  mosquito  proof,  and  that  it 
be  made  attractive,  be  clean  and  well  managed,  so  that  the  people 
may  be  drawn  to  it  and  feel  that  they  will  be  as  well  or  better 
cared  for  in  the  hospital  as  in  their  own  homes.  The  greater  the 
number  of  fever  patients  that  can  be  removed  to  the  hospital  the 
easier  will  be  the  task  of  stamping  out  the  disease. 

Such  cases  as  in  the  opinion  of  the  sanitary  officer  can  not  be  prop- 
erly screened  in  their  homes  should  be  compelled  to  go  to  the  hospital. 
The  transfer  of  the  patient  must  be  accomplished  with  such  pre- 
cautions as  will  prevent  the  possibility  of  his  being  bitten  by  a  mos- 
quito— under  a  mosquito-bar  or  in  a  screened  ambulance. 

3.  Martial  law. 

To  make  the  inspection  thorough  and  effective  and  to  compel  the 
transfer  of  the  sick  to  the  hospital  when  necessary,  authority  is  re- 
quired. In  a  republican  form  of  government  this  authority  is  usually 
wanting  and  these  measures  have  to  be  carried  out  inefficiently  and 
in  the  face  of  great  opposition. 

To  obviate  this  the  writer  would  advocate  that  martial  law  be  de- 
clared in  epidemics  when  the  conditions  are  such  as  to  warrant  it. 
This  legal  procedure  is  frequently  invoked  when  the  menace  to  life 
and  property  is  not  nearly  so  great  as  in  an  outbreak  of  yellow  fever 
or  other  infectious  or  contagious  disease. 

With  martial  law  to  support  the  sanitary  officer  the  prophylactic 
measures  herein  advocated  could  be  enforced  in  every  detail  and  an 
outbreak  of  yellow  fever  effectually  controlled.  It  is  easy  to  under- 
stand why  this  agent  was  not  invoked  prior  to  the  demonstration 
of  the  transmitting  factor  of  yellow  fever,  when  our  efforts  to  control 
the  disease  were  rather  vague  and  uncertain;  but  to-day,  when  our 
system  ma}7  be  made  so  precise  and  certain  it  seems  almost  criminal 
not  to  take  advantage  of  such  a  powerful  auxiliary. 

Tii  our  epidemics  (lie  sanitarian,  unsupported  by  authority,  is 
obliged  to  lose  much  precious  time  and  energy  in  his  efforts  to  gain 
the  good  graces  and  plaudits  <d'  the  populace,  so  that  he  may  be  per- 
mitted to  perform  his  work  imtrammeled. 


13 

4.  Detention  camp. 

In  most  epidemics  it  is  necessary  to  provide  means  to  permit  per- 
sons to  leave  the  infected  district  without  danger  of  carrying  the 
disease  elsewhere.  This  may  be  accomplished  by  a  so-called  "  de- 
tention camp,"  where  those  wishing  to  leave  the  infected  locality  may 
do  so  after  being  detained  under  observation  for  the  time  requisite  to 
assure  their  freedom  from  infection. 

With  our  present  knowledge  of  the  transmission  of  yellow  fever 
it  is  unnecessary  to  establish  these  "  camps,"  as  heretofore,  in  out- 
of-the-way  or  inconvenient  places.  On  the  contrary,  they  may  be 
located  with  perfect  safety  within  the  infected  district  so  long  as  the 
detained  persons  are  kept  in  mosquito-proof  quarters  and,  when  their 
period  of  observation  has  terminated,  are  taken  to  their  destination 
in  mosquito-proof  conveyances  while  within  the  infected  area. 

It  is  plain,  however,  that  in  a  properly  educated  community  where 
the  measures  above  advocated  can  be  put  in  practice,  there  will 
scarcely  be  any  necessity  for  a  detention  camp. 

In  the  foregoing  pages  the  writer  has  endeavored  to  outline  a 
scheme  or  plan  of  prophylaxis  which  he  feels  quite  sure  will  do  the 
work  expected  of  it.  The  machinery  is  there,  but  where  is  the  power 
to  set  it  in  motion?  To  start  it  successfully,  smoothly,  and  without 
friction,  some  central  authority  with  the  necessary  means  and  power, 
acting  surely  and  swiftly,  must  be  provided.  This  should  be  the 
function  of  the  Government. 

PROPHYLACTIC  MEASURES  SUGGESTED  BY  THE  FRENCH  COMMISSION 
OP  THE  PASTEUR  INSTITUTE. 

Much  interest  is  attached  to  the  means  of  prophylaxis  suggested 
by  the  results  obtained  hy  the  French  commission  of  the  Pasteur 
Institute  in  their  report  on  the  investigation  of  yellow  fever,  pub- 
lished in  the  Annals  of  the  Institute  in  November,  1903,  to  wit : 

1.  An  injection  of  virulent  blood  serum  which  has  been  heated  for 
five  minutes  at  a  temperature  of  55 °C.  confers  a  relative  immunity, 
which  may  become  complete  if  followed  by  the  injection  of  a  very 
small  quantity  of  virulent  serum. 

2.  The  injection  of  defibrinated  blood  which  has  been  kept  under 
liquid  vaseline  for  eight  days  confers  a  relative  immunity. 

3.  The  serum  of  a  convalescent  is  endowed  with  preventive  proper- 
ties. 

4.  The  immunity  conferred  by  the  serum  of  the  convalescent  is 
still  in  evidence  at  the  end  of  twenty-six  days." 

a  Abstract  of  Report,  French  Yellow  Fever  Commission ;  Annual  Report. 
U.  S.  Public  Health  and  Marine-Hospital  Service,  1904. 


14 

Further  study  on  this  line  may  give  us  an  immunitive  serum  which 
will  be  of  great  value  in  controlling  yellow  fever. 

However,  even  though  we  attain  this  and,  furthermore,  discover 
the  etiological  factor  in  yellow  fever  we  will  still,  in  a  great  measure, 
have  to  depend  on  the  means  of  prophylaxis  herein  outlined,  and  I 
desire,  therefore,  to  impress  upon  the  reader  the  importance  of  edu- 
cation as  a  prophylactic  factor  and  the  necessity  of  clothing  the 
sanitary  officer  with  the  requisite  power  and  authority  to  enforce 
the  measures  that  we  now  have  at  our  command,  which  are  simple 
and  efficient. 

O 


COLUMBIA  UNIVERSITY  LIBRARIES 


0049982087 


